The impact of violence on healthcare workers' mental health in conflict based settings amidst COVID‐19 pandemic, and potential interventions: A narrative review

Abstract Healthcare workers (HCWs) have faced an increased amount of mental health struggles amidst the COVID‐19 pandemic. However, those in conflict‐based settings with fragile healthcare systems meet additional challenges. This study reviews violence, conflict and mental health among HCWs in five countries: Syria, Palestine, Yemen, Afghanistan and Lebanon. Our study reports that HCWs are targeted by violence, bombings, mistreatment and different forms of abuse, including verbal and physical. With the additional burdens of the pandemic including prolonged working hours, limited resources and insufficient humanitarian aid, the healthcare workers fall victim to increased levels of burnout and mental illnesses. The situation leads to dire consequences on their personal lives and professional development, compelling them to quit their job or country all together. Although healthcare workers remain resilient in these conflict‐based settings, immediate interventions are required to prevent violence against them and cater to their rapidly declining mental health.

evaluated the mental health of HCWs during each of the four successive waves of the pandemic, the frequency of sleep problems and anxiety reported during the first phase gradually decreased over time. However, the high levels of depression, workload and perceived stress persisted. Dealing with the Anti-Vaccine Community accounted for an added occupational stressor for the HCWs during the fourth wave, as HCWs found themselves at the receiving end of their threatening and aggression. 4 A systematic review including more than 16,000 HCWs from 15 studies reported exacerbation of violence towards HCWs during COVID-19, and mental health problems to be substantially higher in HCWs who faced Workplace Violence than those who did not. 5 The HCWs face greater challenges in conflict-based settings, such as Syria, 7 Palestine, 8 Yemen, 9 Afghanistan, 10 and Lebanon. 11 Political instability, economic burden, limited resources, lack of safety and a fragile healthcare system, predispose a complex ordeal difficult for HCWs to navigate through. 10 In such settings, the healthcare system has also been repeatedly targeted due to the ongoing political turmoil, costing lives of many HCWs and destruction of several healthcare facilities. [12][13][14] The conflict situation along with the added burden of violence and mistreatment from the masses, 15 worsens the well being of HCWs, making them increasingly susceptible to mental illnesses. As a result, HCWs have also been reported to consider leaving their job or country in an attempt to escape these helpless situations. 16

| Aims of review
This review aims to assess current literature on the impact of violence on the mental health of HCWs for the following conflictbased settings: Afghanistan, Lebanon, Palestine, Syria, and Yemen.
These countries were selected based on their timely relevance within the context of the COVID-19 pandemic. Moreover, the review focuses on providing practical recommendations to protect the healthcare system from conflict, to address the mental health needs of such settings and alleviating the struggles of HCWs.

| Methodology
A search was conducted on PubMed database and Google scholar from January, 2020 to April, 2022, related to the following key terms: "Yemen," "Afghanistan," "Syria," "Lebanon," "Palestine," "Mental Health," "Healthcare Workers," "Qualitative," "Workplace Violence," "conflict," "violence," and "COVID-19." Additionally, the web was searched for relevant information surrounding each conflict setting including news broadcast channels such as Al-Jazeera, and international entities such as World Health Organization, Human Rights Watch, United Nations, and Doctors Without Borders. Articles were selected on the basis of the inclusion criteria, which included cross-sectionals, qualitative studies, systematic reviews, case studies, and reports from various organizations published in English. Exclusion criteria includes articles published in languages other than English.
Qualitative and Cross-sectional Studies were included in the table, and researchers cross-checked the data to avoid any discrepancies.

| COVID-19 and violence on HCWs
The onset of COVID-19 has exponentially demanded more work hours, staff, and patient care quality from HCWs across the globe regardless of how developed and efficient the hospital had been before the pandemic. In addition to these hardships, the families of patients and general communities have shown ill-mannered behavior instead of appreciation towards HCWs. 17 This leads to violence against HCWs which stems from multifactorial conditions that include anxiety, fear of worsening health status of patient, financial instability, expectations of speedy care from HCWs, lack of awareness, stigmatization. 18 The acts of violence against HCWs have surged in the pandemic, these include chaos due to political turmoil, distrust from citizens, attacks from visitors and more factors that revolve around negative public perception of health care systems, in general. Ramzi ZS et al in their recent systematic review and meta-analysis, concluded violence against HCWs to have risen during the pandemic, with the prevalence estimated to be 47% ranging from verbal to physical violence. 19 The study included 17,201 medical staff and the prevalence of workplace violence statistics was irrespective of sample sizes and the age of HCWs. 19  HCWs as an alerting concern among conflict-based settings. 21 The acts of violence have become life-threatening for HCWs, hence deteriorating their mental health. Fear of life, anxiety, PTSD, and depression has been widespread, seeking mental health services as well is not feasible due to lack of resources, stigmatization, and inefficient therapeutic measures. These reasons may prevent HCWs from prioritizing their own well being leading to inability to perform clinical care to the best of their abilities.

| Syria
Although the warfare in Syria has forced the entire population to experience painful processes of displacement, symptoms of mental disorders and feelings of overwhelming distress, 22 the impact of violence on healthcare workers has been gruesome. Attacks on the healthcare system have resulted in the death of more than 900 HCWs and damage to 600 healthcare facilities since 2011. 7 In 2018 alone, 194 attacks on healthcare facilities and ambulances have been verified. 23 Amidst the political turmoil and the onset of COVID-19 pandemic, HCWs in Syria face the brunt of repeated violence, lack of resources and a fragile healthcare system. 7 Workplace violence towards HCWs was studied in the public hospitals of Syria in 2021, 16 24 According to a study published in 2021, more than 80% of the doctors reported to have undergone physical and verbal workplace violence in the span of one year. 16 There is a need for resources to study long term outcomes of violence on mental health among HCWs. Syria would be the one the first places to conduct such study.

| Palestine
Palestinians have faced decades of conflict, traumas and social distress, leading to anxiety and PTSD being the most common mental disorders among the population. 25 With the onset of the pandemic, the healthcare system of Palestine faced a major setback, and the mental health of the healthcare workers deteriorated even further. 8 Healthcare Professionals in Palestine have been reported to feel isolated, anxious and underappreciated during the COVID-19 response. 26 Moreover, healthcare workers in Palestine have also been exposed to work place violence, including verbal and non-verbal violence. 27 A cross sectional study centered around emergency departments in Palestinian hospitals reveals that nonphysical violence mostly included verbal abuses (69.8%), threats (48.4%), and sexual harassments (8.6%). 15 Furthermore, Gaza's fragmented healthcare system found itself in shambles with repeated instances of war. 13 While hospitals were overwhelmed with injured people, two of Gaza's most prominent doctors in Gaza's coronavirus task force, were also killed. 14

| Yemen
The ensuing war in Yemen has fragmented the country and injured, killed and displaced thousands of civilians. 28 It is estimated that an average 25-year-old in Yemen has already lived through 14 armed conflicts. 28 Healthcare facilities in Yemen have been targeted at least 120 times as a result of conflict. 9 In 2020, An-Nasr Hospital in Yemen was attacked twice in 1 week. 29 The onset of the COVID-19 pandemic has frightened HCWs who continuously provide clinical care despite poor preparedness and weak healthcare infrastructure. 30 During year 2020, The Safeguarding Health in Conflict Coalition Yemeni HCWs feeling moderate-severe stress. 32

| Afghanistan
Due to the persistent conflict in Afghanistan, it is reported that more than 85% of the population has personally experienced or witnessed at least one traumatic event in their life. 33 Afghanistan's under-resourced healthcare system is repeatedly subjected to violent attacks as a result of political instability. 34 Due to violence and conflict, 24 health facilities were damaged in the year 2017 and 154 HCWs were injured. 35 This further led to 150 health facilities forcibly closed temporarily due to insecurity and violence, compromising access to the healthcare to 3 million people. 35 The studies have mentioned total 75 attacks on HCWs in 2019 and an attack on a maternity hospital in 2020. 34 During COVID-19, the impact of violence on HCWs and the working conditions were significantly exacerbated by limited staff, restricted humanitarian aid, prolonged working hours, and suboptimal preparedness. 10 HCWs face greater instances of exhaustion, stress and burnout, which negatively influence their mental health.

| Lebanon
Data from Lebanon depicts severe levels of distress among its population. 36 Lebanon is under-resourced to meet the mental health needs of its population as only 5% of the total governmental health budget is allocated to it. 11 HCWs struggle to manage the deteriorating conditions and meet the exceeded burden during COVID-19, thus they face greater stress and lesser motivation to continue their jobs. 11 The experiences of HCWs have worsened due to the healthcare system being targeted with violence and threats. 37 At one instance, four out of 15 HCWs interviewed reported being subjected to verbal or physical abuse by the population. 37 A survey conducted after the onset of the pandemic revealed 61% of the HCWs experiencing moderate to severe symptoms of anxiety, and approximately 50% experiencing sleep disturbances. 38 With the emergence of COVID-19 outbreak, the country is thought to be under a "two-in-one crisis." 38 It is evident that HCWs RIJA ET AL. | 3 of 11 face high risks of burnout and emotional exhaustion in this population, 38 and being violently targeted 39 further pushes their mental health off the edge.

| DISCUSSION
Based on the literature review, violence was found to have a strong association with the rapidly deteriorating mental health of the healthcare workers in conflict-based setting across the world. We have detailed our discussion relevant to each country and Table 1 highlights the studies focusing violence on HCWs in conflict-based settings and its effect on their mental health.

| Syria
Syria has been in a state of violence for over a decade now, with healthcare workers in specific being targets of both judicial and nonjudicial means of persecution. As presented in a particular study, 14.71% have experienced violence, 42.37% have faced civilian bombardment and blockade, 35.59% were detained or arrested and 15.25% experienced attacks on health facilities. 13 Workplace violence against healthcare workers is very prominent in Syria due to the ongoing conflict as well as the burden faced on the healthcare system because of the pandemic.
Another study states that 84.74% of resident doctors face verbal violence, whereas 19.08% face physical violence. 16 The findings also noted that male resident doctors face a significantly higher frequency of violence in comparison to females. 16 Violence has greatly impacted the mental well-being of the workers, along with affecting their job performance and job satisfaction. 16 Many healthcare workers have experienced a rise in anxiety and depression along with poor sleep. 16 Based on results delivered by a study, 15.9% of the practitioners worked 10-12 h daily. 40 Along with violence and staff shortage, the healthcare system also lacked proper equipment and resources. The study shows 43.3% of healthcare workers claim their facility does not provide the required equipment to protect them against acquiring COVID. 40 As a result of the current condition, 72.4% of workers had poor sleep quality and 17% showed severe stress disorder. 40 The ongoing Syrian conflict has resulted in the displacement of millions of Syrians, while making the lives of those still in the country challenging. 41 The dire conditions surrounding the healthcare system contribute to the rapid decline of the mental health of HCWs, compelling up to 70% HCWs to leave the country. 7

| Palestine
Palestinians are not only battling with a pandemic but also with Israeli occupation and violence. The fear of mass bombings and killings further exacerbates feelings of anxiety and depression caused by the pandemic. HCWs are also subjected to this violence, two well-known doctors were killed due to bombings, 14 and the only COVID-19 testing laboratory in Gaza was destroyed due to an airstrike. 14 The healthcare workers in Palestine have been reported to feel exhausted fighting alone in the pandemic, in the absence of the support that they need. 26 Previous studies have provided evidence for high levels of burnout among HCWs. 42 Exposure to violence, especially physical violence at workplace is one of the factors associated with such levels of burnout. 42 A study has reflected violence on about 75% healthcare staff included in the study, mainly inflicted by the patients' families and visitors. 15 The violence adopted many forms; physical and nonphysical, including verbal abuse, threats, and sexual harassment. 15 In another study conducted in 2021, 7.2% of the study population reported participating in nonverbal violence and 19.6% participating in verbal violence against the healthcare workers. 27 Such events are thought to be under-reported and are majorly attributed to the absence of appropriate consequences against them. 15 This lack of a healthy and safe working environment negatively affects the mental health of HCWs, their patient care and willingness to continue their job. 15  Elnakib's study. 44 Lawlessness and insecurity have made violence accessible to militias, and hence accounts of raids, shelling, and gunfire at residences of HCWs or their family members have been reported.

| Yemen
In the face of delivering healthcare services, HCWs lose their own lives as they become targets during travel, or upon arrival. Witnessing or hearing such traumatic incidents impacted mental wellbeing. There have even been instances of HCWs feeling like they must relive those traumas or violent encounters. Some HCWs even expressed shame at their incapacity and helplessness, which has directly contributed to self-doubt. 44 Unsafe working conditions, fears of threats or harassment, and roadblocks when leaving for work in the morning are some of the challenges HCWs face. This has resulted in greater distress for HCWs who are emotionally and physically exhausted before they even reach their workplace. 44 Paralleling the spread of COVID-19, armed conflict intensified in Aden following April 2020, which is expected to have worsened conditions for HCWs in this area. 45

| Afghanistan
According to a report published in 2019, 140 health facilities in Afghanistan were reported to be forcefully shut down by armed groups. 46 In May 2020, a militant attack was directed at a governmentrun Maternity Hospital in the Afghan Capital, claiming 24 lives. 47 15 mothers, three of whom were in the delivery room, two young boys and a local midwife were among those killed. 48 Three HCWs and two newborn babies were injured. 48 Since, Médecins Sans Frontières (Doctors Without Borders) were assisting the hospital in healthcare provision, an attack planned at them predisposed them to increased vulnerability and harm, forcing them to exit the hospital practice. 49 Community Health Workers have also expressed ill-treatment at the hands of both, the healthcare system and the general population. They are viewed to not have best interests at heart and are blamed for the suboptimal health services and an ineffective healthcare system in rural settings. 50 During the pandemic in 2020, Action on Armed Violence monitoring project reported Afghanistan to be the worst impacted country globally, 12

| Lebanon
In particular, HCWs have been victimized by violence and harassment.
Especially when hospitals could not admit any new patients amidst the pandemic, some healthcare workers became targets of violent attacks. 37 While doing their jobs, patients or their families threatened and physically assaulted the healthcare providers. 37 In an interview with Human Rights Watch, Abou Sharaf, Head of the Lebanese Order of Physicians, stated that at least one serious attack on a physician occurs every month. 37 An emergency room doctor at a private hospital in Saida reported several occasions of patients' families attacking healthcare workers or damaging the intensive care unit after not being allowed to visit their sick relatives. 37 Apparently, one incident involved people smashing the glass barrier and attacking caregiver. 37 Gunmen have used hospitals to fire weapons, drawing fire in return. 39  HCWs must be shielded from aggression and violence through introduction of additional policies and implementation of the existing legislation. 16 In a study conducted in Syria, 16

| Clinical research and registries
The data coming out from each conflict setting is fractured and nonharmonized. The effect on HCWs mental well being is not well studied and its impact on patient clinical care is even less studied. The need of the hour to develop and sustain near real time clinical registries 54-57 to capture harmonized clinical data from hospitals, HCWs and patients.

| CONCLUSION
In conclusion, HCWs in conflict-based settings fall target to multilayer of violence and mistreatment, subsequently increasing their susceptibility to mental illnesses. In spite of countries' specific challenges, HCWs also have demonstrated remarkable levels of resilience. This review article sheds light on the possible interventions and the urgent need for their timely implementations to shield the healthcare system from violence and improve the mental well-being of HCWs in conflict-based settings.